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In this retrospective study, 79 digits of 55 patients received 102 secondary procedures following replantation. We divided the procedures into two groups, occurring before or after 2 months following replantation. The procedures in the early group were mainly for soft tissue coverage (92%), and those in that late group were mainly for tendon (67%) to improve function. Factors associated with higher incidence of early secondary procedures included multiple-finger injury, avulsion or degloving injury and level of injury proximal to zone III in finger replantation (p

Thirty-seven consecutive free anterolateral thigh flaps in 36 patients were transferred for reconstruction of head and neck defects following cancer ablation between January of 1997 and June of 1998. The success rate was 97 percent (36 of 37), with one flap lost due to a twisted perforator. The anatomic variations and length of the vascular pedicle were investigated to obtain better knowledge of anatomy and to avoid several surgical pitfalls when it is used for head and neck reconstruction. The cutaneous perforators were always found and presented as musculocutaneous or septocutaneous perforators in this series of 37 anterolateral thigh flaps. They were classified into four types according to the perforator derivation and the direction in which it traversed the vastus lateralis muscle. In type I, vertical musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 56.8 percent of cases (21 of 37), and they were 4.83 +/- 2.04 cm in length. In type II, horizontal musculocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 27.0 percent of cases (10 of 37), and they were 6.77 +/- 3.48 cm in length. In type III, vertical septocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 10.8 percent of cases (4 of 37), and they were 3.60 +/- 1.47 cm in length. In type IV, horizontal septocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 5.4 percent of cases (2 of 37). They were 7.75 +/- 1.06 cm in length. The average length of vascular pedicle was 12.01 +/- 1.50 cm, and the arterial diameter was around 2.0 to 2.5 mm; two accompanying veins varied from 1.8 to 3.0 mm and were suitable for anastomosis with the neck vessels. Reconstruction of one-layer defect, external skin or intraoral lining, was carried out in 18 cases, through-and-through defect in 17 cases, and composite mandibular defect in two cases. With increasing knowledge of anatomy and refinements of surgical technique, the anterolateral thigh flap can be harvested safely to reconstruct complicated defects of head and neck following cancer ablation with only minimal donor-site morbidity.

A total amputation of the superior part of an ear with associated avulsion of adjacent scalp was treated successfully with a 'fan' technique, in which we unfolded the posterior skin envelope from the amputated ear segment and spread it onto part of the scalp defect of the temporal region. This resulted in a large area of contact between the composite graft and its recipient bed, with the added bonus of covering up some of the scalp defect. The remaining defect of the scalp was grafted with part of the avulsed scalp.

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 x 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 +/- 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.

Reconstruction of combined loss of the Achilles tendon and overlying soft tissue was performed using an antero-lateral thigh free flap in three patients. The cutaneous portion is used to cover the open wound, and a piece of fascia lata is utilised to replace the missing segment of the Achilles tendon. The skin defect ranged from 5 x 2.5 to 7 x 5 cm, and the tendon loss measured from 3.5 to 5.5 cm in length. All of the patients showed satisfactory functional results with a follow-up period from 3 to 9 months. The advantages of the procedure are that: it is a single-staged operation; it promotes rapid healing of the tendo Achilles since the tendon substitute is well vascularised; it is adaptable to a wide range of defect sizes and shapes; it can be performed in the supine position without the need for postural change; and it can restore good contour and causes minimal morbidity at the donor site.